Introduction
Cognitive-behavioral sex therapy/pain management and physical therapy (PT) are the main nonmedical interventions available to women with vulvodynia, while more recent options include hypnosis and acupuncture. Although these four modalities are widely used in the multidisciplinary treatment of musculoskeletal chronic pain problems [1] with success rates comparable to that of other medical interventions [2], they remain under-recommended in the treatment of vulvodynia.
This chapter describes cognitive-behavioral therapy (CBT), PT, and alternative treatments for vulvodynia from both clinical and scientific perspectives. Specifically, we (1) explain the rationale underlying the use of psychological and pelvic floor rehabilitation interventions; (2) detail the main strategies and techniques that comprise each of these two interventions; (3) summarize the empirical evidence concerning the effectiveness of CBT, PT, acupuncture, and hypnosis; and (4) emphasize the need to approachthetreatmentofvulvodynia fromamultimodal, multidisciplinary perspective.
Why Manage Vulvodynia with Psychotherapy and Pelvic Floor Rehabilitation?
Because psychological andPT interventions are less mainstream in comparison to medical management of vulvodynia, they are often less obvious treatment choices. Nonetheless, there are compelling reasons for their use in the treatment of vulvar pain. First, CBT is the only treatment that directly targets distressing sexual and couple issues. Second, CBT provides psychological support to women and couples grappling with a misunderstood condition that may generate feelings of shame, anger, inadequacy, and hopelessness. Third, individual and dyadic psychological factors have been shown to contribute to the experience of vulvar pain [3]. Fourth, psychological approaches to pain management have been shown to be successful in terms of diminished pain intensity and frequency of pain behaviours, and improved coping [4]. Fifth, CBT leads to reduced pain intensity and catastro-phizing, improved sexual functioning, and treatment satisfaction in women with provoked vestibulodynia (PVD) [2]. Lastly, it is a great complement to another nonmedical intervention, pelvic floor rehabilitation.
In terms of pelvic floor PT and its rationale, a controlled study conducted by Reissing et al. [5] showed that women with PVD present with significantly more pelvic floor muscle hypertonicity than pain-free controls. These findings suggest that pelvic floor dysfunction may contribute to the development and maintenance of vulvar pain and should be targeted via pelvic floor rehabilitation in PT. Furthermore, retrospective and prospective studies have shown that PT and biofeedback help women with PVD reduce their pain and improve their sexual functioning [6].
It can become even more worthwhile to combine CBT and PT into an integrated form of care that may allow women to avoid the negative sexual side effects of certain pain medications and the invasiveness of vestibulectomy [7]. Indeed, both interventions share similar goals and strategies (e.g., the use of systematic desensitization to decrease the fear of pain and penetration), and they can possibly potentiate each other’s effectiveness via a simultaneous focus on mind and body [8].
Psychological Interventions
Psychological interventions range from pain education and exposure-type exercises such as vaginal dilation, to more sophisticated, in-depth psychotherapy focusing on issues related to relationship discord or psychosexual development. We have developed a CBT group treatment for women with PVD [9]. For some patients, these ten group sessions will be enough to bring about satisfactory improvements in pain and sexual functioning. Others will shy away from such a format and prefer individual and/or couple therapy sessions tailored specifically to their clinical presentation. With parsimony guiding our clinical approach, we prefer to begin with CBT strategies and work our way toward more intensive psychotherapy when necessary; that is, when the patient expresses this need or when too many roadblocks impede progress via short-term treatment.
Keeping this framework in mind, the goals of CBT are to enable patients to: reconceptualize vulvodynia as a multidimensional pain problem influenced by cognitive, emotional, behavioral, and couple factors; modify such factors to help increase adaptive coping (e.g., reduce pain catastrophizing) and decrease pain intensity; improve the quality of women and/or couples’ sexual functioning, and steer the focus away from intercourse with a view toward developing more positive attitudes about other pleasurable sexual activities; reduce avoidance of physical intimacy and nonpenetrative sex; facilitate adherence to other treatment regimens (e.g., medical management) and assessment and intervention procedures (e.g., gynaecological examinations); and consolidate skills and maintain gains.
The treatment generally includes the following:
1 information about the nature of CBT;
2 education and information about vulvodynia and how it impacts negatively on desire, arousal, and orgasm;
3 education concerning a multifactorial view of pain and the interdependentroles of cognitive, affective, behavioral, relationship, and biomedical factors in the maintenance of persistent pain;
4 use of a pain diary;
5 relaxation techniques;
6 exposure exercises such as vaginal dilation (i.e., inserting increasingly larger fingers into the vagina while in a relaxed state);
7 cognitive restructuring exercises (i.e., replacing distorted or irrational beliefs about pain and sexuality with realistic ones);
8 distraction techniques focusing on sexual imagery;
9 rehearsal of coping self-statements; and
10 communication skills training related to romantic relationships, in particular, the expression of emotional needs and sexual preferences.
Because more substantial work concerning sexual desire, intimacy, or other systemic issues may be warranted, the partner should be included in the process as much as possible, although this need not be via formal couple therapy. This may allow the partner to receive needed support, and may develop both partners’ awareness of, and empathy for what each is experiencing.
In our clinical experience, we have found that patients do not always fit into our neatly elaborated treatment programs. It is thus necessary to develop a flexible attitude and tailor the treatment to the needs of each patient, while making pain and sexual impairment the central focus of therapy. This has the benefit of validating the woman’s suffering, strengthening the therapeutic alliance between patient and health professional, and facilitating parsimony and cost-effectiveness.
Pelvic Floor Rehabilitation
Some patients notice their hypertonic pelvic floor, especially during attempted penetration, and know intuitively that this tension may be contributing to their pain experience. Pelvic floor PT has the advantage of being short term (6–10 sessions) and may be seen as less threatening than CBT because the focus of PT is not on talking about intimate aspects of their sex lives.
Related posts:
Stay updated, free articles. Join our Telegram channel
Full access? Get Clinical Tree
